Мініінвазивні технології в хірургії жовчнокам’яної хвороби, ускладненої механічною жовтяницею

Abstract

Entry. Mechanical jaundice is frequent complication of gallstone disease both in urgent and in planned surgery. In the last few years the increase of amount of patients with mechanical jaundice, especially persons of elderly and senile age, is marked and the results of their treatment don’t satisfy surgeons fully. A similar situation cannot remain regardless and requires the search of new ways of decision of this problem. Research aim. Determination of the most optimal methods of diagnostics and treatment of patients with the gallstone disease complicated by mechanical jaundice and estimation of efficiency of their application. Materials and research methods. The results of laparoscopic cholecystectomy in 3054 patients with gallstone disease and its complications are analyzed. Experience of surgical treatment of 297 (9,7%) patients with gallstone disease complicated by mechanical jaundice is presented. The most frequent complications were: choledocholithiasis, mechanical jaundice - in 290 (9,5%) patients, combination of choledocholithiasis with stenosis of large duodenal papilla - in 218 (7,1%), stricture of choledoch - in 7 (0,2%). Endoscopic papillosphincterotomy and laparoscopic cholecystectomy was performed for 263 (8,6%) patients with mechanical jaundice. Research results. On the I stage of treatment of mechanical jaundice in 263 (8,6%) patients with choledocholithiasis and combination of choledocholithiasis with stenosis of large duodenal papilla endoscopic papillosphincterotomy was performed. On the II stage of treatment of patients laparoscopic cholecystectomy was conducted. It was performed on the 2-7 days after endoscopic papillosphincterotomy and verification of the absence of stones in choledoch. The new method of implementation of laparoscopic cholecystectomy the key moment of which is subserosal coagulation of branches of cystic artery is described. The curatively-diagnostic algorithm of treatment of patients with gallstone disease complicated by mechanical jaundice is offered. Conclusions. The most informative method in diagnostics of choledocholithiasis, complicated by mechanical jaundice, is endoscopic retrograde cholangiopancreatography (85,4% - 95%). Endoscopic papillosphincterotomy is the most effective for patients with the diameter of stones in choledoch less than 10 mm. At a diameter more than 10 mm endoscopic papillosphincterotomy in most cases is ineffective. Such patients must undergo the operative intervention by an open method. Usage of two stage of treatment of the gallstone disease complicated by mechanical jaundice must be priority. We consider the first stage must include combination of endoscopic retrograde cholangiopancreatography and endoscopic papillosphincterotomy, the second stage – laparoscopic cholecystectomy. The method of gall-bladder devascularisation at laparoscopic cholecystectomy with the use of subserosal coagulation of small branches of cystic artery without selection and ligation of her main branch is the effective method of extrahepatic bilious ducts and main (cystic and hepatic) arteries damage prophylaxis.